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Hospital Competition and Charity Care WORKING PAPERS Hospital Competition and Charity Care Christopher Garmon WORKING PAPER NO. 285 October 2006 ___________________________________________________________________________ FTC Bureau of Economics working papers are preliminary materials circulated to stimulate discussion and critical comment. The analyses and conclusions set forth are those of the authors and do not necessarily reflect the views of other members of the Bureau of Economics, other Commission staff, or the Commission itself. Upon request, single copies of the paper will be provided. References in publications to FTC Bureau of Economics working papers by FTC economists (other than acknowledgment by a writer that he has access to such unpublished materials) should be cleared with the author to protect the tentative character of these papers. ______________________________________________________________________________ BUREAU OF ECONOMICS FEDERAL TRADE COMMISSION WASHINGTON, DC 20580 Hospital Competition and Charity Care Christopher Garmon1 Bureau of Economics Federal Trade Commission Washington, DC Draft: October 2006 Abstract: This paper explores the relationship between competition and hospital charity care by analyzing changes in charity care associated with changes in a hospital’s competitive environment (due to mergers and divestitures), using hospital financial and discharge data from Florida and Texas. Despite the pervasive belief that competition impedes a hospital’s ability to offer services to the uninsured and under-insured, I find no statistically significant evidence that increased competition leads to reductions in charity care. In fact, I find some evidence that reduced competition leads to higher prices for uninsured patients. 1 The views expressed in this paper are the author’s, not necessarily those of the Federal Trade Commission or any individual Commissioner. I would like to thank Marissa Crawford and Michelle Kambara for their valuable research assistance on this project. I would also like to thank Gloria Bazzoli, Denis Breen, Cory Capps, Martin Gaynor, Daniel Hosken, participants at the American Society of Health Economists Conference, and anonymous referees for their helpful comments and suggestions. Any remaining errors are my responsibility. 1. Introduction In 2003, over 25 percent of the U.S. population under age 65 lacked health insurance at some point during the year. Almost 14 percent of the U.S. population under age 65 was uninsured for the entire year.2 For many of the uninsured, but particularly those with low incomes and high annual health care usage, charity care by health care providers represents a large fraction of the healthcare they receive. For the uninsured overall between 1996 and 2000, 64 percent of their healthcare was charity care. For uninsured families of four with incomes less than $51,0003 and average annual healthcare usage greater than $10,000, 87 percent of their health care was charity care.4 Given the relatively large number of Americans who lack health insurance and their dependence on charity care, it is surprising how little research exists about the effect of competition on the provision of charity care. This may be due to the widespread belief that increased competition inhibits a provider’s ability to offer charity care because managed care payers pay less with more provider competition. In other words, many believe that insured patients, particularly managed care and privately insured patients, cross-subsidize a hospital’s charity care. If a hospital must charge less to private payers due to increased competition, it will have fewer resources to treat the uninsured. As one author recently stated: “The more the financing of hospital care moves in the direction of a ‘perfect’ market, the less and less funding for community service there will be.”5 Throughout the health policy literature, this view of the inverse relationship between competition and charity care is seen as almost tautological. However, having market power does not imply that it will be used for philanthropy. Certainly, there is no expectation of this with a for-profit firm, but many hospitals are non-profit entities. The expectation is that non-profit hospitals have their community’s welfare as an 2 Rhoades (2005) 3 This is 300% of the poverty threshold in 2000. 4 Herring (2005) 5 Vladeck (2006), page 42 2 objective, so they will provide free or below cost services to those in need. (In fact, previous theoretical models of charity care model it as a direct argument of the hospital’s utility function.) Recently, the behavior of non-profit hospitals in providing charity care has been called into question. Several high-profile lawsuits have been filed against non-profit hospital systems accusing them of providing too little charity care and over-charging the uninsured.6 Congress recently convened hearings to investigate whether non-profit entities (including hospitals) provide community benefits commensurate with their status. A GAO report prepared for those hearings found that the difference between the average charity care provided by non-profit hospitals and that provided by for-profit hospitals was surprisingly small and, in one of the five states studied, was even negative. 7 It is possible that hospitals (non-profit and for-profit) treat their uninsured patients much as recent research suggests they treat their managed care customers when obtaining market power: by increasing the effective price or, in the case of the uninsured, reducing charity care. In any event, the effect of competition on hospital charity care is an empirical question, one that has received little attention, particularly in the past ten years. The only published articles, of which I am aware, that investigate the relationship between competition and charity care are Frank and Salkever (1991), Gruber (1994), Mann et al. (1995), and Mann et al. (1997). Frank and Salkever’s results imply that overall charity care will increase as the number of hospitals increase (holding overall beds constant), but their model is 6 See Weissman (2005); By law, hospitals with emergency rooms must at least stabilize patients before transfer regardless of ability to pay and some states and local jurisdictions have additional access regulations, so some charity care is mandated by law. However, for private hospitals, much charity care is at the hospital’s discretion. First and foremost, uninsured patients are, at least initially, faced with the hospital’s “billed charges” (i.e., list price) for their services, not the discounted prices most insured payers face. Except in Maryland, these charges are set by each hospital or system. In addition, hospitals set their charity care policy (e.g., based on patient income) and its accessibility, if they have an explicit charity care policy. Hospitals also exercise discretion in how aggressively they attempt to collect bad debt and/or how readily they convert it to “charity care” retroactively. 7 GAO (2005) 3 estimated using data from Maryland, where hospital prices are regulated. Using California data, Gruber (1994) and Mann et al. (1995) both find that charity care decreases faster in relatively competitive markets than in relatively uncompetitive markets in response to an exogenous reimbursement change affecting all hospitals (e.g., switch from a charge based system to a prospective payment system for Medicare). Although closely related, these latter two findings don’t directly address the relationship between competition and charity care. Gruber, in particular, investigated the effect of the regime shift in California in 1983 that allowed selective contracting by health insurers on the provision of charity care and how this varied across competitive conditions. He found that charity care fell more in relatively competitive markets in response to this regime change, but did not report whether it remained higher than or fell below the charity care provided in less competitive markets. Likewise, Mann et al. (1995) investigated the effect of Medicare and Medi-Cal reimbursement changes on charity care and its relationship to competition. They also found that charity care fell more in competitive markets, but one table8 suggests that it remained higher than in less competitive markets. Mann et al. (1997) again report that hospitals provide more uncompensated care in competitive markets, but also find that “the greater the degree of HMO penetration, the lower the provision of uncompensated care relative to the hospital’s size, with the effect being stronger in the most competitive markets.”9 None of these papers investigate the effect of competition changes (i.e., mergers and divestitures) on charity care. Apart from Mann et al. (1997), the previous studies used data exclusively from the early and mid 80's, before the rise of managed care and subsequent backlash of recent years. In this paper, I investigate the relationship between changes in competition and changes in charity care using hospital financial and discharge data from Florida and Texas from 1999 and 2002. Florida and Texas are two of the few states that report detailed hospital financial information including charity care, bad debt and the net revenue received from uninsured patients. The hospital markets in Florida and Texas are not price-regulated, allowing the possibility that a hospital could use additional market power rents from managed care customers 8 Exhibit 2 on page 267 of Mann et al. (1995). 9 Mann et al. (1997), page 230. 4 to increase charity care. In addition,
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